Citation

Green RS, Palatnick W. J. Emerg. Med. 2003; 25(3): 283-287.

Copyright

(Copyright © 2003, Elsevier Publishing)

DOI

10.1016/S0736-4679(03)00204-X

PMID

unavailable

Abstract

The use of sulfonylurea medications in the treatment of type 2 diabetes mellitus is common. Patients who present to the Emergency Department after ingestion of excessive amounts of suflonylurea medications often have hypoglycemia refractory to dextrose administration. Standard care includes the administration of dextrose, glucagon, and diazoxide. Recently, the use of octreotide has been described as an alternative treatment in these patients. We present a case of a 20-year-old woman who ingested 900 mg of glyburide causing refractory hypoglycemia resistant to treatment with intravenous dextrose, glucagon, and diazoxide. Octreotide administration rapidly reversed hypoglycemia allowing patient stabilization and eventual discharge without any significant adverse events. © 2003 Elsevier Inc.; Indications:1 patient with refractory sulfonylurea (glyburide [glibenclamide])-induced hypoglycemia.; Patients:One 20 year old woman. (inpatient); TypeofStudy:A case report describing the effectiveness of Sandostatin in refractory sulfonylurea (glyburide [glibenclamide])-induced hypoglycemia.; DosageDuration:100 mcg iv for 2 doses.; Results:After 10 hours in the ED and with recurrent symptomatic hypoglycemia, the patient was administered Sandostatin along with an ampule of D50W for a finger prick glucose of 1.9 mmol/L (34 mg/dL). The measured glucose rapidly improved, with a range of 6.8 to 11.7 mmol/L (117-211 mg/dL) over the next 7 hours. The patient was asymptomatic during this time. Due to the lack of inpatient beds, the patient was kept in the ED observation unit. Nine hours after Sandostatin administration, the measured glucose decreased to 2.9 mmol/L (52 mg/dL), and Sandostatin was again administered intravenously. The glucose stabilized and only one ampule of D50W was needed immediately after Sandostatin. The patient was discharged from the ED observation unit 29 hours after admission, and 36 hours after presentation to the nursing station, in good condition. Psychiatric evaluation of the patient in the ED revealed no indication for inpatient care, and follow up with the psychiatric service was arranged. In addition to at least two meals and oral dextrose supplementation, the patient received 10 ampules of D50W, greater than 6 L of dextrose containing fluid, and 450 mg of diazoxide before stabilization with intravenous Sandostatin. The patient was discharged to a monitored community setting, and telephone follow up with the patient and caregiver confirmed that she had no signs or symptoms of hypoglycemia after leaving the ED.; AdverseEffects:No adverse events were mentioned.; AuthorsConclusions:In conclusion, our patient illustrates the benefits of octreotide use in glyburide-induced hypoglycemia. We recommend its use in patients who present with hypoglycemia refractory to dextrose after a sulfonylurea overdose.; FreeText:The patient had a history of previous suicide attempts and was brought to a nursing station in an isolated rural community after ingesting 180 5 mg tablets of glyburide (approximately 900 mg) less than 1 hour previously. The patient was noted to be tremulous and diaphoretic but was alert and oriented. Immediate treatment with oral dextrose was initiated, as intravenous access was unsuccessful. Finger prick glucose recorded 40 minutes after arrival was found to be 3.6 mmol/L (65 mg/dL), heart rate 88 beats/min, and O2 saturation 98% on room air. The patient was further treated with 50 grams of activated charcoal by mouth, repeated oral dextrose, and glucagon 1 mg intramuscularly on the advice of a physician via telephone. Seventy minutes after presentation, an intravenous line was established and D5W1/2NS was infused as fast as possible. A repeat finger prick glucose measurement found the patient's glucose to be 11.6 mmol/L (209 mg/dL) and arrangements for air transfer to a referral hospital were made. Finger prick glucose was monitored every 15 minutes, and despite continuous infusion of D5W1/2NS in addition to repeated oral dextrose, the glucose ranged from 2.9 to 11.3 mmol/L (52-204 mg/dL). The patient was noted to be anxious, tremulous, diaphoretic, tachycardic, and tachypneic, which corresponded to a low measured glucose during this period. Before arrival in the referral Emergency Department (ED), the patient received a total of 3.0 L of D5W1/2NS, 225 grams of oral dextrose, 2 ampules of D50W (50 grams dextrose in 50 mL water), and 1 mg of glucagon. On arrival, the patient was found to be asymptomatic with heart rate 90 beats/min, blood pressure 142/78 torr, respiratory rate 18 breaths/min, and a temperature of 36.9 C (tympanic). Initial finger prick glucose in the ED was 5.2 mmol/L (94 mg/dL), 5 hours after presentation to a health care facility. Less than 1 hour after admission to the ED, the patient was found again to be tremulous and lethargic with a finger prick glucose of 2.1 mmol/L (38 mg/dL). Administration of 1 ampule of D50W failed to resolve the hypoglycemia and a repeat finger prick glucose was 2.4 mmol/L (43 mg/dL). The patient continued to have recurrent hypoglycemia not responsive to repeated administration of D50W and oral dextrose. Diazoxide 150 mg iv was administered approximately 5 hours after ED admission, but a repeat finger prick glucose was found to be only 2.1 mmol/L (38 mg/dL). A repeat dose of diazoxide 300 mg was then administered after 2 ampules of D50W, but the measured glucose did not improve to greater than 3.8 mmol/L (68 mg/dL).

Language: en

Keywords

Toxicology; Hypoglycemia; Octreotide; Oral hypoglycemics; Sulfonylureas